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Glycemic Control is not Related to Postextraction Healing in Patients with Diabetes
DIAGNOSIS/TREATMENT/PROGNOSIS
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION The relationship of glycemic control to the outcomes of dental extractions. Aronovich S, Skope L, Kelly J, Kyriakides T. J Oral Maxillofac Surg 2010;68:2955-61.
Glycemic Control is not Related to Postextraction Healing in Patients with Diabetes
SUMMARY Subjects
REVIEWER Kaumudi Joshipura, BDS, MS, ScD
PURPOSE/QUESTION To determine whether glycemic control among patients with diabetes influences healing after tooth extraction
SOURCE OF FUNDING Information not available
TYPE OF STUDY/DESIGN Cohort study
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Not applicable
The sample size was 115, with 56% women. The study was conducted in the Hospital of Saint Raphael, New Haven, Connecticut. Participants 18 years and older with known history of insulin-dependent diabetes mellitus or non–insulin-dependent diabetes mellitus (NIDDM) and use of related medications, requiring dental extractions were recruited between October 2007 and July 2008. Exclusion criteria were recent antibiotic or steroid use, steroid-induced glucose intolerance, systemic immunodeficiency, chemotherapy, radiation therapy, nonlocalized odontogenic infection, and surrounding tissue pathology or lesion. Asymptomatic patients with preoperative random glucose levels greater than 180 mg/dL were referred to their medical providers for improved glycemic control and were excluded. Routine extractions were performed by the oral surgery residents, and sutures were placed to reapproximate the mucoperiosteal flap with no modifications to the treatment rendered specifically for the study. Patients were followed for 2 weeks, which was sufficiently long to assess healing, but only 78 participants had complete follow-up data.
Key Exposure/Study Factor The primary exposure was glycemic control, which was assessed by random glucose (well controlled: # 180 mg/dL; poorly controlled: $ 180 mg/dL) and by glycosylated hemoglobin (HgbA1c # 7.0%, HgbA1c of 7.1% to 9.0%, and HgbA1c $ 9.0%). Nonfasting random blood glucose levels were obtained with a glucose meter, and updated glycosylated hemoglobin values were obtained from the hospital laboratory or the patient’s primary care physician whenever possible.
Main Outcome Measure The primary outcome variable, epithelialization rate, was obtained by measuring the extraction socket with a periodontal probe in a buccolingual orientation. Epithelialization was determined in millimeters as the difference in extraction socket width between postoperative days (PODs) 0 and 7, between PODs 7 and 14, and between PODs 0 and 14.
Main Results
J Evid Base Dent Pract 2011;11:187-188 1532-3382/$36.00 Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2011.09.012
The main results are presented in Tables 8 and 9 of the article. There was no statistically significant difference in the rate of postextraction epithelialization between patients with diabetes with preoperative BG levels of 180 mg/dL or less and those with levels greater than 180 mg/dL. There was no statistically significant difference in the rate of postextraction epithelialization among patients with diabetes with glycosylated hemoglobin levels of 7.0% or less, 7.1% to 9.0%, or greater than 9.0%.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Conclusions This prospective, observer-blinded study showed no difference in postextraction epithelialization, a measure of healing, between well-controlled and poorly controlled diabetic patients.
COMMENTARY AND ANALYSIS The article by Aronovich et al1 is the first prospective study evaluating the association between diabetes control and postextraction healing. The authors enrolled 115 patients who required dental extractions and had a known history of type 2 diabetes (including people treated with insulin or on a hypoglycemic). Although the follow-up was only 2 weeks long, with follow-up visits at 7 and 14 days postoperatively, only 68% of the patients had complete follow-up data. The loss to follow-up may have led to bias if the attrition was related to the glycemic control and healing. Extraction procedures were conducted by a number of different residents, which may have introduced substantial variation in technique and expertise and likely may have influenced healing. In addition, the teeth to be extracted varied in location, tooth type, and condition, affecting the degree of difficulty of the extraction. This is difficult to quantify, but would also influence healing. Although the outcome measures were assessed by observers blinded to the level of control of diabetes, the residents performing the extractions were not blinded to the patients’ diabetes control levels and may have taken more care in the extractions for patients with poor control, which could have biased the results toward the null. An important concern is that asymptomatic patients who were poorly controlled (random glucose > 180 mg/dL) were excluded. Thus, patients with poor control were only those with symptomatic dental conditions as opposed to the well-controlled patients, which included those with symptomatic or asymptomatic teeth requiring extraction. In addition to reducing the sample size of poorly controlled participants, the selective exclusion of those with poor control and asymptomatic dental conditions may have biased the results toward the null. The major concern is the exposure measures. The random blood glucose would likely have a large withinperson variation owing to the different consumption of foods, energy expenditure, and missing medications, and does not adequately portray diabetes control, especially in poorly controlled individuals.2,3 Although the glycosylated hemoglobin is more robust and reflects glycemic control over the past 2 to 3 months,4 the mea-
188
sure was obtained in a nonstandardized way (from the hospital laboratory or patient’s physician) as and when ever possible, and it is not clear how many participants were excluded because of missing values, which may again have biased the results. Also, the participants were divided into arbitrary groups based on HbA1c levels, and the choice of cutoffs was not justified. The authors cite an article referencing duration of diabetes as a risk factor for implant failure.5 Although the duration of diabetes varies greatly, the authors do not evaluate duration as a factor for healing. The authors do not consider duration of diabetes or other factors that may affect healing in the analyses. The conclusions are consistent with the data presented, and the research question is of clinical significance; however, the sample size is small and the study has some limitations, as noted previously. Hence, additional larger studies are needed. In the meantime, the decision to operate on a patient with hyperglycemia, suggestive of uncontrolled diabetes, should remain at the discretion of the individual surgeon.
REFERENCES 1. Aronovich S, Skope LW, Kelly JP, Kyriakides TC. The relationship of glycemic control to the outcomes of dental extractions. J Oral Maxillofac Surg 2010;68(12):2955-61. 2. Gill GV, Hardy KJ, Patrick AW, Masterson A. Random blood glucose estimation in type 2 diabetes: does it reflect overall glycaemic control? Diabet Med 1994;11(7):705-8. 3. Otieno FC, Ng’ang’a L, Kariuki M. Validity of random blood glucose as a predictor of the quality of glycaemic control by glycated haemoglobin in out-patient diabetic patients at Kenyatta National Hospital. East Afr Med J 2002;79(9):491-5. 4. Del Nero E, De Lorenzi E, Granata L, Carta G, Magro G, Tigani A, et al. [Evaluation of the changes in glycosylated hemoglobin in a sample of hospitalized diabetic patients. Significance and limitations of this diagnostic method]. Clin Ter 1990;133(6):387-91. 5. Olson JW, Shernoff AF, Tarlow JL, Colwell JA, Scheetz JP, Bingham SF. Dental endosseous implant assessments in a type 2 diabetic population: a prospective study. Int J Oral Maxillofac Implants 2000; 15(6):811-8.
REVIEWER Kaumudi Joshipura, BDS, MS, ScD Professor of Epidemiology, NIH Endowed Chair and Director, Center for Clinical Research and Health Promotion, School of Dental Medicine, University of Puerto Rico, PO Box 365067, San Juan, PR 00936, Phone: 787-237-0009, 787-758-2525 x. 2585; Fax: 787-753-4868 [email protected]
December 2011
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION The relationship of glycemic control to the outcomes of dental extractions. Aronovich S, Skope L, Kelly J, Kyriakides T. J Oral Maxillofac Surg 2010;68:2955-61.
Glycemic Control is not Related to Postextraction Healing in Patients with Diabetes
SUMMARY Subjects
REVIEWER Kaumudi Joshipura, BDS, MS, ScD
PURPOSE/QUESTION To determine whether glycemic control among patients with diabetes influences healing after tooth extraction
SOURCE OF FUNDING Information not available
TYPE OF STUDY/DESIGN Cohort study
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Not applicable
The sample size was 115, with 56% women. The study was conducted in the Hospital of Saint Raphael, New Haven, Connecticut. Participants 18 years and older with known history of insulin-dependent diabetes mellitus or non–insulin-dependent diabetes mellitus (NIDDM) and use of related medications, requiring dental extractions were recruited between October 2007 and July 2008. Exclusion criteria were recent antibiotic or steroid use, steroid-induced glucose intolerance, systemic immunodeficiency, chemotherapy, radiation therapy, nonlocalized odontogenic infection, and surrounding tissue pathology or lesion. Asymptomatic patients with preoperative random glucose levels greater than 180 mg/dL were referred to their medical providers for improved glycemic control and were excluded. Routine extractions were performed by the oral surgery residents, and sutures were placed to reapproximate the mucoperiosteal flap with no modifications to the treatment rendered specifically for the study. Patients were followed for 2 weeks, which was sufficiently long to assess healing, but only 78 participants had complete follow-up data.
Key Exposure/Study Factor The primary exposure was glycemic control, which was assessed by random glucose (well controlled: # 180 mg/dL; poorly controlled: $ 180 mg/dL) and by glycosylated hemoglobin (HgbA1c # 7.0%, HgbA1c of 7.1% to 9.0%, and HgbA1c $ 9.0%). Nonfasting random blood glucose levels were obtained with a glucose meter, and updated glycosylated hemoglobin values were obtained from the hospital laboratory or the patient’s primary care physician whenever possible.
Main Outcome Measure The primary outcome variable, epithelialization rate, was obtained by measuring the extraction socket with a periodontal probe in a buccolingual orientation. Epithelialization was determined in millimeters as the difference in extraction socket width between postoperative days (PODs) 0 and 7, between PODs 7 and 14, and between PODs 0 and 14.
Main Results
J Evid Base Dent Pract 2011;11:187-188 1532-3382/$36.00 Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2011.09.012
The main results are presented in Tables 8 and 9 of the article. There was no statistically significant difference in the rate of postextraction epithelialization between patients with diabetes with preoperative BG levels of 180 mg/dL or less and those with levels greater than 180 mg/dL. There was no statistically significant difference in the rate of postextraction epithelialization among patients with diabetes with glycosylated hemoglobin levels of 7.0% or less, 7.1% to 9.0%, or greater than 9.0%.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Conclusions This prospective, observer-blinded study showed no difference in postextraction epithelialization, a measure of healing, between well-controlled and poorly controlled diabetic patients.
COMMENTARY AND ANALYSIS The article by Aronovich et al1 is the first prospective study evaluating the association between diabetes control and postextraction healing. The authors enrolled 115 patients who required dental extractions and had a known history of type 2 diabetes (including people treated with insulin or on a hypoglycemic). Although the follow-up was only 2 weeks long, with follow-up visits at 7 and 14 days postoperatively, only 68% of the patients had complete follow-up data. The loss to follow-up may have led to bias if the attrition was related to the glycemic control and healing. Extraction procedures were conducted by a number of different residents, which may have introduced substantial variation in technique and expertise and likely may have influenced healing. In addition, the teeth to be extracted varied in location, tooth type, and condition, affecting the degree of difficulty of the extraction. This is difficult to quantify, but would also influence healing. Although the outcome measures were assessed by observers blinded to the level of control of diabetes, the residents performing the extractions were not blinded to the patients’ diabetes control levels and may have taken more care in the extractions for patients with poor control, which could have biased the results toward the null. An important concern is that asymptomatic patients who were poorly controlled (random glucose > 180 mg/dL) were excluded. Thus, patients with poor control were only those with symptomatic dental conditions as opposed to the well-controlled patients, which included those with symptomatic or asymptomatic teeth requiring extraction. In addition to reducing the sample size of poorly controlled participants, the selective exclusion of those with poor control and asymptomatic dental conditions may have biased the results toward the null. The major concern is the exposure measures. The random blood glucose would likely have a large withinperson variation owing to the different consumption of foods, energy expenditure, and missing medications, and does not adequately portray diabetes control, especially in poorly controlled individuals.2,3 Although the glycosylated hemoglobin is more robust and reflects glycemic control over the past 2 to 3 months,4 the mea-
188
sure was obtained in a nonstandardized way (from the hospital laboratory or patient’s physician) as and when ever possible, and it is not clear how many participants were excluded because of missing values, which may again have biased the results. Also, the participants were divided into arbitrary groups based on HbA1c levels, and the choice of cutoffs was not justified. The authors cite an article referencing duration of diabetes as a risk factor for implant failure.5 Although the duration of diabetes varies greatly, the authors do not evaluate duration as a factor for healing. The authors do not consider duration of diabetes or other factors that may affect healing in the analyses. The conclusions are consistent with the data presented, and the research question is of clinical significance; however, the sample size is small and the study has some limitations, as noted previously. Hence, additional larger studies are needed. In the meantime, the decision to operate on a patient with hyperglycemia, suggestive of uncontrolled diabetes, should remain at the discretion of the individual surgeon.
REFERENCES 1. Aronovich S, Skope LW, Kelly JP, Kyriakides TC. The relationship of glycemic control to the outcomes of dental extractions. J Oral Maxillofac Surg 2010;68(12):2955-61. 2. Gill GV, Hardy KJ, Patrick AW, Masterson A. Random blood glucose estimation in type 2 diabetes: does it reflect overall glycaemic control? Diabet Med 1994;11(7):705-8. 3. Otieno FC, Ng’ang’a L, Kariuki M. Validity of random blood glucose as a predictor of the quality of glycaemic control by glycated haemoglobin in out-patient diabetic patients at Kenyatta National Hospital. East Afr Med J 2002;79(9):491-5. 4. Del Nero E, De Lorenzi E, Granata L, Carta G, Magro G, Tigani A, et al. [Evaluation of the changes in glycosylated hemoglobin in a sample of hospitalized diabetic patients. Significance and limitations of this diagnostic method]. Clin Ter 1990;133(6):387-91. 5. Olson JW, Shernoff AF, Tarlow JL, Colwell JA, Scheetz JP, Bingham SF. Dental endosseous implant assessments in a type 2 diabetic population: a prospective study. Int J Oral Maxillofac Implants 2000; 15(6):811-8.
REVIEWER Kaumudi Joshipura, BDS, MS, ScD Professor of Epidemiology, NIH Endowed Chair and Director, Center for Clinical Research and Health Promotion, School of Dental Medicine, University of Puerto Rico, PO Box 365067, San Juan, PR 00936, Phone: 787-237-0009, 787-758-2525 x. 2585; Fax: 787-753-4868 [email protected]
December 2011